The AAFP is closely monitoring implementation of G2211 and will update this page as CMS releases more information.
The care you provide your patients is complex and comprehensive. G2211 will help you get paid more accurately for it. Starting January 1, 2024, use this new add-on code alongside office/outpatient evaluation and management (E/M) codes to receive additional payment for the high-value visits you provide.
Healthcare Common Procedure Coding System (HCPCS) add-on code G2211 reflects the time, intensity, and practice expense resources involved when physicians provide office/outpatient visits that build longitudinal relationships with patients and address the majority of a patient’s health care needs with consistency and continuity over longer periods of time.
The Centers for Medicare & Medicaid Services (CMS) created code G2211 to better account for the resource costs associated with visit complexity inherent to primary care and other longitudinal care.
The 2024 national Medicare allowable for G2211 is $16.05.
Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)
HCPCS code G2211 is payable starting January 1, 2024.
G2211 is an add-on code that may be reported with new and established patient office/outpatient evaluation and management (E/M) services.
✔️ Use the add-on code when you are the continuing focal point for all health care services the patient needs. Per CMS, the relationship between the patient and the physician is the determining factor of when the add-on code should be billed.
✔️ G2211 only applies to office and outpatient E/M services (CPT codes 99202-99215).
Do not use G2211 when:
❌ Your relationship with the patient is of a discrete, routine, or time-limited nature. For example, a physician who sees a patient for an acute concern should not report HCPCS G2211 if they have not also assumed responsibility for the patient’s ongoing medical care or do not plan to take responsibility for subsequent, ongoing medical care with consistency and continuity over time.
❌ The associated office visit E/M is reported with modifier 25 appended.
Get the facts about why G2211 is needed.
Let them know that:
According to the guidance in the Medicare Learning Network Matters: How to Use the Office and Outpatient (O/O) Evaluation and Management Visit Complexity Add-on Code G2211:
“You must document the reason for billing the O/O E/M visit. The visits themselves would need to be medically reasonable and necessary for the practitioner to report G2211. In addition, the documentation would need to illustrate medical necessity of the O/O E/M visit. We [CMS] haven’t required additional documentation. Our [CMS] medical reviewers may use the medical record documentation to confirm the medical necessity of the visit and accuracy of the documentation of the time you spent. These items could serve as supporting documentation for billing code G2211:
Private payers (including commercial and Medicare Advantage) and Medicaid are not required to cover and pay separately for G2211, and their policies will vary. The AAFP encourages you to review your contracts and speak with your provider relations representatives about adding G2211 to your fee schedule.
The AAFP is strongly advocating that private payers cover and pay for G2211 across all lines of business. Additional information regarding the AAFP’s advocacy efforts can be found on the Decoding G2211: Myths Versus Facts webpage.
CMS has not explicitly defined "single, serious condition, or complex condition." However, they have provided HIV and sickle cell disease as examples. Their guidance emphasizes the importance of the longitudinal relationship and serving as the continuing focal point for all of the patient's health care needs. The complexity captured by G2211 is not related to the condition itself. Further, CMS notes, "Add-on code G2211 includes services that enable practitioners to build longitudinal relationships with all patients (that is, not only those patients who have a chronic condition or single, high-risk disease) and to address the majority of patients' health care needs with consistency and continuity over long periods of time.”
Since FQHCs and RHCs are paid an encounter rate rather than based on the complexity of the patient, G2211 will be bundled into the FQHC prospective payment system rate and the RHC all-inclusive rate.
No, G2211 is not restricted based on medical specialty. CMS emphasizes that it could be reported by physicians with office visit E/M visits for care that serves as the continuing focal point for all needed health care services (e.g., primary care physicians) and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or complex condition.
Yes, G2211 is subject to Medicare’s deductible and coinsurance.
Additional information on Modifier 25:
Understand how to properly document and code for E/M services.